Discussion of interesting or befuddling cases related to pulmonary and critical care medicine.

Tuesday, March 14, 2006

Lung mass

This is a 75 y/o woman sent to us for an abnormal CxR. She has a 60 pack-year Hx of smoking and COPD and a remote Hx of histoplasmosis (she had a respiratory infection consistent with acute histo ~40 years ago). She has a moderately severe obstructive defect with physiologic evidence of emphysema.She has the following finding on her CT with an additional left adrenal mass. What would you do next? Would you approach the chest mass or the adrenal first?

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Presuming the radiologist does not think that the adrenal mass is an adenoma by CT criteria, I would go after that lesion. If it is positive for lung cancer, you have a diagnosis and a stage.If you biopsy the chest first, you still will need to know the histology of the adrenal lesion.Assuming she is unresectable based upon her COPD (is this right?), treatment if the adrenal lesion is negative may be "curative" XRT and chemo; if the adrenal lesion is positive, your patient would likely get chemo alone and only XRT if she became symptomatic (chest wall pain from the location of the lesion).

I had the sam exact thoughts as Mike L. The adrenal looks very suspicious on CT and doesn't look like a simple adenoma. However, in talking to our CT radiologist the adrenal is in a bad position: fairly high up, hiding by LLL and would be hard to get a CT-guided Bx. Her PFTs would be borderline but she should tolerate a lobectomy if the adrenal was negative.

I considered a PET, but if the lung is + and the adrenal is -, would you go ahead and resect the lung lesion? If the PET is + in both lesions (or negative in both), you're in the same spot as now.

So, I think you need to go for the adrenal first. If they can't get it by Ct-guided biopsy, a laparoscopic procedure may be necessary (and still probably less harmful than doing a lobectomy for potential stage 4 lung Ca.)

Interestingly, there are apparently some data that, in some cases, you can resect a solitary adrenal met and the lung primary (analogous to resecting a solitary brain met).

I would get a PET scan first...If adrenal is negative and chest is positive, I will feel much less concerned about the adrenal mass being malignant..(already on CT it has features of Adenoma....a negative PET would be even more convincing..and for those still in doubt, MRI can be done). another issue here is whether the lung mass involves the adjacent ribs/chest wall or not, as that will affect staging....and that may not be easy to tell.

Actually, the statement was that the adrenal does not look like an adenoma. I agree that a PET would be helpful with regards to likelihood--if the lung mass and adrenal mass have different PET "signatures", then the adrenal is unlikely to be a metastasis from the lung mass.

It looks like the chest wall may very well be involved. If so, it is T3N0 (Stage 2B-presuming no involved nodes that you failed to tell us about). Either way, it is resectable. The differntiating factor here is the adrenal, and I think that evaluation of the adrenal has to be the priority; it is the difference between Stage 2B or lower, and Stage 4 disease.